- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $2,772.16 / $4,232.51
| Facility | | $1,400.00 | $2,772.16 | $4,232.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,358.52 / $2,772.16 / $3,814.54
| Professional | | $2,358.52 | $2,772.16 | $3,814.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,867.34 / $3,277.76 / $3,571.18
| Facility | | $2,867.34 | $3,277.76 | $3,571.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,628.60 / $3,174.38 / $3,174.38
| Professional | | $1,628.60 | $3,174.38 | $3,174.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,070.20 / $3,070.20 / $3,070.20
| Facility | | $3,070.20 | $3,070.20 | $3,070.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,374.96 / $3,576.22 / $7,358.13
| Professional | | $2,374.96 | $3,576.22 | $7,358.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.26 / $3,064.38 / $4,365.35
| Professional | | $2,116.26 | $3,064.38 | $4,365.35 |